General Information

This is required to determine insurance eligibility. Please call our office if you prefer not to provide online.
Please provide a specific time if needed

Employer Information

If NO occupation, Please leave BLANK

DENTAL Insurance Information

Please provide Dental Insurance under which you are covered. This may be Spouse's Dental Insurance.

Dental History

If you do not have a current dentist, please respond: None

Medical History

This section will determine if there are any medical concerns that may interfere with orthodontic treatment
This includes Fosamax, or medications known as Bisphosphonates